Narrative Review on Causes of Obesity Prevalence in Ethnic Indians and Strategies to Prevent It

This dissertation will use a narrative review method to critically analyze research literature related to the prevalence of obesity in ethnic Indian population. The research design will involve the use of explicit eligibility criteria to identify high-quality research articles related to the research questions.

Running head: NARRATIVE REVIEW
Narrative review on causes of obesity prevalence in ethnic Indians and strategies to prevent it
Name of the student:
Name of the University:
Author’s note

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Table of Contents
1. Introduction:................................................................................................................................2
Background:.................................................................................................................................2
Significance of the study:............................................................................................................4
Research Gap of previous studies:...............................................................................................5
Research questions:.....................................................................................................................8
Research aim:...............................................................................................................................9
Research objective.......................................................................................................................9
2.Methodology:..............................................................................................................................10
Research design:............................................................................................................................10
Search strategy:..........................................................................................................................11
Data collection:..........................................................................................................................12
Data analysis..............................................................................................................................13
Results............................................................................................................................................14
Trends in obesity in India..........................................................................................................14
Dietary habits and obesity.........................................................................................................15
Genetic factors and obesity........................................................................................................17
Ethnicity and Obesity................................................................................................................18
Physical activity and obesity.....................................................................................................20
Sugar intake and obesity............................................................................................................22

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Socioeconomic status and obesity prevalence...........................................................................23
Television ownership and TV time:..........................................................................................24
Strategies to prevent obesity in ethnic Indian population..........................................................25

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1. Introduction:
Obesity has become a growing public health issue because of related co-morbidities
associated with the condition and increase in health expenditure related to the allocation of health
care resources for the management of obesity. A person is defined as obese when his body mass
index (BMI) is greater than 30kg/m2. Furthermore, extreme obesity is diagnosed when a person
has BMI of greater than 40 kg/m2 (1). Although it is a high burden for high income countries,
however the prevalence of obesity in middle and low income countries is also turning out to be a
burden for public health department. According to World Health Organization (WHO), obesity is
a highly neglected problem in developed and developing countries (2). In case of India, ethnic
difference in obesity has been found as a research study revealed regional differences in obesity
statistics and its risk for North Indians, South Indians and North East Indians (3). As obesity is
associated with many co-morbid health conditions like type 2 diabetes, hypertension and non-
alcoholic fatty liver disease, taking adequate steps to understand the cause behind prevalence of
obesity in specific section of population is important (4). Childhood obesity is also an issue as it
is a precursor to obesity and non-communicable disease. As obesity epidemic is increasing in
Indians, the main purpose of this dissertation is to look at the issue of high prevalence of obesity
in ethnic Indian population and conduct a narrative review of research literatures to understand
the factors that contribute to obesity in ethnic Indian population. The process of narrative review
will help to critically understand the facilitators of obesity and identify strategies that can be
implemented to prevent obesity and make people aware about the risk associated with obesity.

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Background:
India is the second most populated country in the world and great diversity exist in terms
of populations statistics as different ethnic groups like Mongoloid, Dravidians and Indo-Aryans
reside in the country (5). As India is a multi-ethnic country, a research study aimed to explore
about ethnic difference in obesity through analysis of differences in socio-cultural background.
Variations in ethnic groups were examined in three different ethnic groups residing in Manipur,
Delhi and Kerala. Females in Delhi were found to be the heaviest followed by Manipur and
Kerala (6). The variations in adiposity patterns were justified by the contribution of genetic
factors and environmental sources in causing obesity (7). Hence, the findings gave the
implication that ethnicity is a complex construct and many factors unique to ethnic group socio-
cultural environment might also help to identify the cause behind obesity in Indians. Therefore,
more research work on factors contributing to obesity in ethnic population group will be
importance.
A review of research on obesity prevalence and trends in Indian population revealed that
obesity and overweight issues in children are increasing and the problem is evident not only for
children coming from higher socio-economic group, but also for people under the low income
group (8). High consumption of energy rich food, sedentary lifestyle, genetic, behavioural and
environmental factors play a role in the pathogenesis of obesity (9). This can eventually lead to
poor health in future such as mental disorders, respiratory issues and glucose intolerance. The
study revealed that there is a trend towards increase in obesity (8). However, the limitation of the
work was that it lacked data related to ethnic wise and gender wise differences. Hence, to get
better understanding regarding obesity trend in India, there is a need to compare data related to
ethnic specific cut points and gender related difference to identify the cause behind obesity. For

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developing country like India, the challenges is that it has been already dealing with malnutrition
and underweight issues and the latest trend of obesity in children is a new unique challenge for
public health. Hence, it can be said that India is undergoing both epidemiological and nutritional
transitions now and gaining an in-depth understanding regarding the impact of this transition on
obesity is important.
Research study investigating about cause of obesity has revealed lack of awareness
regarding obesity and increased attitude towards consuming unhealthy food are some of the
cause behind increase in prevalence of obesity (10). Another rational for the significance of this
research project is that findings obtained from this project can indirectly help to reduce the
burden of non-communicable disease (NCD) too (11). This is said because of the links between
obesity and NCD. Obesity and being overweight is one of the modifiable risk factors of obesity
and reducing the rate of obesity is one of the approach to ameliorate rate of NCDs in community
too (12). According to recent data, NCD accounted for 6.7 million deaths in South East Asia
Region in 2012 (13). Obesity and sedentary lifestyle has been identified as the major risk factors
of NCD. In rural areas too, gradual shift in lifestyle has been seen because of the advent of mass
media and modernization. Mass media is a powerful mechanism that changes taste and
preferences and interest of the people (14). Therefore, identifying the influence of changing
dietary patterns and level of physical activity in the context of demographic transition in India is
important.
Significance of the study:
Many research studies have explored the cause of obesity prevalence because of changes
in nutrition profile of India. However, many limitations or shortcomings in those research
pointed out to the need for conducting research on cause behind obesity prevalence in ethnic

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Indian population. In the past, India suffered because of persistent burden of under-nutrition.
However, during the Millennium Development era, India witnessed rapid changes in nutrition
profile of the national population because of increase in number of obese children (15).
According to a study done on remission of overweight among men and women in India, it was
found that prevalence of overweight was 19% among men and 27.2% among women. In
addition, the remission rate was found to be highest among men compared to women. People in
the age group of 25-35 years and 36-49 years were found to have higher odds of being
overweight (16). This suggests that nutrition transition in rural East Indian district has resulted in
growth of burden due to obesity. The study gave no link regarding increased in burden due to
low socioeconomic status. However, the factors leading to increase in obesity in ethnic Indian
population was left to be examined. Hence, these gaps in previous research literature signified
the significance of this dissertation as it aims to explore all factors that contribute to obesity in
ethnic people by conducting a narrative review of research literature.
The research in the area of cause behind rise in obesity in ethnic population in India is
significant as it could pave way to understand socio-cultural, environmental and behavioural
factors that encourage people to consume unhealthy food and increase their odds of being obese.
To identify specific preventive strategies needed to reduce obesity prevalence, more extensive
research on wider ethnic population in India is needed to gain an insight regarding the cause of
obesity prevalence among ethnic Indian adults. The narrative review method can help to
understand specific factors that contribute to the burden of obesity in specific population of India
such as the young age group and the ethnic group.

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Research Gap of previous studies:
Many research studies have explored obesity prevalence and identified links between
social and environmental factors contributing to obesity. A recently published research literature
gave the idea that India is dealing with the pressure of both over nutrition and under nutrition. In
some areas, energy deficiency is an issue affecting population health whereas in other areas
obesity and its associated disease is acting as a public health problem. In a period of 14 years,
rapid change in obesity prevalence has been seen in the rural population. The main reasons
behind this change are improve in transport facilities, family income, educational status and food
habits (17). Another research study investigated about the prevalence of obesity in ethnic groups
such South Asian Indians and Africans by measuring data related to body weight, height and
waist circumferences. Gender specific differences in ethnic Indian population were found.
However, the researcher argued that effective implementation of obesity prevention strategies are
hampered because of misclassification about adiposity excess and disease risk (18). Hence, there
is a need to take into account gender and ethnicity while reviewing epidemiological data on
obesity in Indian population. A better interpretation of numbers and statistics is necessary to
identify the risk factors of obesity and address barriers that impede prevention of obesity for
youths and adults in the Indian community.
Obesity is a condition that is influenced by multiple factors like genetic, demographic and
lifestyle factors. Although genetic factors and demographic factors like ethnicity and age cannot
be modified, however lifestyle factors are modifiable (19). For this reason, a study evaluated
about socioeconomic, demographic and lifestyle determinant of obesity in Northeast Indian. The
cross-sectional study with Rengma-Naga individuals living in Assam revealed an association
between age, education and income. Rapid urbanization and changes in lifestyle because of

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socioeconomic development are some factors that lead to prevalence of obesity (20). For this
reason, currently health promotion staff pays more attention to lifestyle choices among people to
determine their risk of being obese or overweight. However, the study had gaps as it lacked
details regarding the factors contributing to obesity. No proper research method was used that
could have helped to explore risk factors in details. Hence, getting wider data is important for the
development of appropriate intervention programs to target obesity reduction in India.
An increasing trend towards obesity is also seen in Indian children. This is evident from
the report that prevalence of childhood obesity and childhood overweight reached 19.3% in 2010
compared to 16.3% in 2001-2005 (8). In the era of globalization, a study identified the advent of
mass media as one of the factor contributing to changed dietary preferences. Television has been
recognized as one source that increases the incidence of obesity in children by exposing children
to advertisement for fast food, sugar sweetened beverage and high sugar foods. Hence, content of
food advertising on Indian television was judged by the researcher and the study revealed lack of
any advertisements that displayed nutritional content of the marketed food (21). As per India’s
Food Safety and Regulations standards 2011, it is necessary that food packaging and
advertisements pay attention to education and health rather than taste and convenience (22).
However, despite implementation of such legislations, unhealthy food advertising dominates in
Indian television. One of the gap found in this study was that it gave data for affluent section of
community and there was a need to identify the impact of television advertising on children
coming from poor socioeconomic background. Hence, the gaps suggested the need to review
studies that focuses on vulnerable people such as ethnic Indian and rural population group at risk
of obesity in India.

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Past research has also explored physical activity profile of ethnic groups to understand
the factors contributing to obesity among ethnic people. A cross-sectional survey based study
investigated about urban differences in diet, physical activity and obesity in India. The survey
was done in Punjab and the study indicated about few dietary and physical activity differences in
urban and rural population of Punjab. For example, the rural group people were found to
consume salt in high quantity compared to urban participants. In addition, rural females were
found to engage in vigorous activity compared to urban females (23). Hence, the urban and rural
study revealed poor dietary practices and physical inactivity as a factor that contributes to NCD
in India. However, certain biases in research affected the credibility and reliability of the
research findings. For example, the data was collected by a self-reported survey where there is a
possibility that answers might be manipulated by research participants. Another aspect is that
diversity of physical activities across different cultural groups in India has not been captured.
Hence, reviewing studies with detailed describing across culture and daily life activities are
needed to identify the influence of leisure time and diet on obesity and risk of other comorbid
disease in target population group.
To overcome the gap identified in past research, narrative review method has been
chosen for this dissertation to increase the objectivity of research data. The use of explicit
eligibility criteria may help to find high quality research related to factor contributing to obesity
in Indian population and retrieve those articles that have rigorous methodological approaches
(24). The narrative review method can help to describe the study findings from a contextual point
of view (25). The approach may help to appraise previous studies and speculate new types of
interventions that can be implemented to control obesity in ethnic Indian population.

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Research questions:
The main purpose of research is to find out answer to the following research question:
 Why the prevalence of obesity in young children and adults in the ethnic Indian
population is increasing?
 What are the factors that influence obesity in the ethnic Indian population?
 How can these factors be addressed to reduce the prevalence of obesity in ethnic Indian
population?
Research aim:
The dissertation aims to find out the following by conducting a narrative review of
research literature:
 To find out the reason of increase in the prevalence of obesity in the ethnic Indian
population.
 To investigate the factors of obesity in order to introduce effective strategies to mitigate
the issue of obesity in the ethnic Indian population.
 To provide adequate information to determine how can these factors be addressed to
reduce the rate of obesity in ethnic Indian population.
Research objective
The main objectives of the dissertation are as follows:
 To retrieve relevant research articles from database search to identify the factors leading
to obesity in India
 To identify strategy to reduce obesity issue in young children and adults in India

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 To present research finding in the form of themes
2. Methodology:
Narrative review is a method of investigation in which findings of a research literature are
evaluated by considering contextual context, theoretical approach and themes related to the
research findings (26). In response to the issue of obesity prevalence in ethnic Indians, the
narrative review method has been chosen to interpret research data related to cause of obesity in
more details. The chapter provides an insight into the research paradigm and epistemiology used
to conduct research on the topic of cause of obesity in young and adult ethnic Indian population.
Details on the research design have been provided along with rational for the research design in
relation to the research aim and study objective. The chapter provides an insight into the search
strategy used to retrieve articles for the research and defines the method that has been used to
extract, analyse and interpret results obtained from the study.
Research design:
As the research aims to get in-depth understanding regarding the phenomenon of obesity
prevalence in India, narrative review method has been chosen as a research design. Narrative
review method can be defined as a research design which reviews different types of primary
research studies and holistically interpret research findings using existing theories and contextual
context (27). The main rational for choosing narrative review method for the topic is that it
favours collecting qualitative data related to research findings. The issue of obesity prevalence in
ethnic Indian requires qualitative data to understand environmental, cultural and socio-political

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factors unique to the target group that leads to obesity in certain sections of the population. To
identify best strategies to reverse the trend of increasing obesity prevalence among ethnic
Indians, it is essential to have large amount of qualitative data to understand the reason behind
increase in over-nutrition (91). Hence, narrative review approach provides the scope to collect,
compare and contrast qualitative data related to obesity prevalence in ethnic Indian groups (28).
The advantage of using narrative review method is that it provides the scope to review and
interpret diversities of research topic. Use of robust research method during the data analysis
process may have positive implications for health care decision making (29). As many gaps has
been identified in past research literature related to the topic of obesity in ethnic Indians, the
effectiveness of using narrative review method is that it can help to summarize previous research
and identify areas which has not been addressed till now. This may help to find the solution to
obesity prevalence in India.
Search strategy:
The narrative review method is guided by the selection of appropriate databases and search
process to obtain articles relevant to the research question. Critical reflection on best approach to
search for evidence is important to increase the quality of the review and fulfil the research
objective (30). For this narrative review, the search for article was done in MEDLINE database
and the main rationale for taking MEDLINE was that it is a globally recognized database that
publishes lots of research done in the field of biomedical and health sciences. Hence, searching
for articles from MEDLINE can increase the possibility of getting as many relevant research
articles as possible (31). Another advantage of using MEDLINE database is that it has powerful
search features that can make the search process narrow and specific to the research question.

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Inclusion of search limiters supports research to take the right lead while conducting the research
(32).
As the main objective is to find out the cause behind obesity prevalence in ethnic Indians and
identify effective strategies to control obesity in the target population, MEDLINE and CINAHL
database was selected as the primary source of research studies. Other search engines used for
article search included Google scholar.. The key words to be used for the search in database
included ‘obesity and ethnic Indians’, ‘obesity prevalence and ethnic Indians’, ‘Cause of obesity
in ethnic Indians’ and ‘factors contributing to obesity in ethnic Indians’. The use of Boolean
operators like AND and OR was also used to conduct search in CINAHL database. Similar
search terms like obesity or overweight or obese Indians were combined with OR to find articles
similar in meaning. The search limiters that were applied included setting the publication date to
2009 to 2018. This was done to retrieve articles published within 10 years of research and find
out the changes that has happened in the past 10 years leading to obesity in ethnic Indian
population. This is important as it would help to achieve the research objective of getting an
awareness regarding the cause of obesity and the prevalence of obesity among ethnic Indians.
The keywords used and the hits obtained has been summarized in appendix 1. The final selection
of articles was dependent on inclusion and exclusion criteria for research. These were as follows:
 Only those research articles could be selected which were relevant to the research
question:
 All the research study must explore about the factors contributing to obesity in ethnic
Indians
 The research must be done within 2009 to 2018
 The research must be published in English language

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 All types of research methodology such as cohort studies, qualitative studies, policy
documents and recommendations from health organizations were analyzed.
 The exclusion criteria were to rule out those articles which were published before
2009 and those which were published in other language.
Data collection:
After comparing the research articles obtained from database search based on inclusion and
exclusion criteria, the research articles were screened by first looking at abstract and title of the
articles. The full-text article was then reviewed. The article was included in the review after a
consensus was achieved regarding the relevance and quality of the research articles in
comparison to the research question. The details regarding the screening and eligibility process is
provided in appendix 2. The process of obtaining consensus also enhances the credibility and
reliability of research information (33). A summary table for each study was also created that
gave a brief idea regarding the research aim and outcome and the same has been attached in
appendix 3. The articles were also critically appraised according to key findings, limitations,
suitability of the research design, quality of the results obtained and interpretation of results. This
approach would help to find the best study that answers the research question as well as identify
research limitations that affect the transferability of the research outcome. This has been done by
using CASP tool as a guideline to critically evaluate research rigor in research studies. This was
done by evaluating the research evidence by reviewing research design, recruitment method,
rigor in research and credibility of research findings. Evaluation of research methodology is the
most important part of the analysis process as this method helps to identify possible sources of
bias and confounders and their impact in research.

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Data analysis
Qualitative research approach is the main framework that is used in case of research
exploring human experience. To make the research valued in evidence based practice, it is
essential to complete it in a rigorous manner to obtain meaningful results (34). Data analysis is
the most vital part of qualitative research and being clear about the appropriate data analysis
method is essential to increase trustworthiness of the research process (35). While analysing the
research findings, it has been planned to adapt narrative analysis approach to present the research
findings. This approach would help to reformulate all research findings by taking into account
the contextual factors affecting results and experiences of research participants (36). The main
focus is to compare and contrast research data and identify common themes and patterns in
research. The process of coding, decontextualizing and recontextualizing of research data may
help to evaluate rigor and trustworthiness of research (34). The research findings can be further
be reviewed to identify vital information that was missing and which was needed to answer the
research question. This form of analytical skill would help to conduct a high quality and
narrative review that discusses key issues as well as contradictory findings as per the research
question.
A research study defines narrative analysis using themes as a rigorous research method to
identify sensitive and trustworthy research findings. It is a flexible approach in research that can
be used across range of epistemiologies and research questions (37). Hence, as per the needs of
researcher, thematic analysis provides theoretical freedom to researchers and supports them in
getting rich and detailed data. It offers accessible form of analysis and well-structured approach
to form research data. However, some disadvantage is that novice research who do not have idea
regarding how to conduct a rigorous thematic method may face difficulty as there is less amount

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of literature on thematic analysis process (34). Despite this, critical reflection on rigor in research
and approach taken to minimize bias in research may help to correctly evaluate and appraise
research literatures. The themes were generated by identifying results which have similar
meaning and them categorizing them into themes.

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Results
Introduction:
This chapter provides an insight into themes that has been obtained in relation to the
research question. The studies with similar meanings has been grouped together and included in
on theme. The narrative review starts with interpretation of the theme related to trends in obesity
prevalence and then summarizes other themes related to the research question. These includes
dietary habits and obesity, genetic factors and obesity, ethnicity and obesity, sugar intake and
obesity, socioeconomic status and obesity prevalence, impact of television ownership on obesity
and prevention of obesity. The review of the 23 articles obtained can summarize the findings
obtained in relation to the research question.
This chapter aims to analyse the results in relation to the research aims and objectives.
The illustrations of the results will be done in relation of the research questions via the
generation of the themes obtained review of the articles. The thematic analysis was done via
critical review of articles because according to Polit and Beck (2008) a review of literature
mainly involves critical analysis of the available research in order to contextualise the prevailing
problem in healthcare. The thematic analysis was conducted via the use of 23 odd articles which
were shortlisted via the review of abstract, inclusion and exclusion criteria and review of the
article title.
Research questions Themes

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To retrieve relevant research articles from database
search to identify the factors leading to obesity in
India
Trends in obesity in India
Dietary habits and obesity
Genetic factors and obesity
Ethnicity and obesity
A total of 23 articles were selected for the narrative review process. The whole summary
for search process and number of articles removed and excluded is provided in appendix 2. The
initial records obtained from database search included 157 papers and additional 17 were
obtained from review of other online papers.60 articles were removed initially as they were
found to be similar piece of work with changes in publication date. The second phase of
screening of articles was done by reviewing abstract and title of research articles determining its
suitability as per the research question. Based on this criteria, 55 articles were excluded. The next
process of determining the eligibility of the research was done by comparing research articles
according to the inclusion and exclusion criteria. The 72 articles were evaluated using the
eligibility criteria and 40 articles were excluded as it gave details on obesity for children or it
gave results on other cultural groups living in other countries. Hence, 23 articles were obtained
after the screening and eligibility process.
The themes for the study were generated in the following ways:
Phase 1: After the data collection process, each selected research studies were thoroughly read
several times and similar types of information were highlighted and picked out to make notes.
The main meanings were labelled using different codes and colours and categorized together to
develop themes.

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Phase 2: All the notes, underlined keywords and different meanings were listed and categorized
under different themes. This process helped to develop themes which has been presented and
discussed in details below.
Trends in obesity in India
India is the second most populous country in the world and at present is experiencing
rigorous epidemiological transition. Under-nutrition arising out of poverty mainly dominated
India in the past, at present India is dominated by obesity. The main factor which contributes
obesity among the ethnic Indian population is industrialization and urbanization. There are
mainly three types of obesity prevalent in India and this includes abdominal obesity (AO),
combined obesity (CO) and generalised obesity (GO). All the ethnic groups who are residing in
India like the Indo-Aryan (North Indian), Mongoloid (North East Indian) and the Dravidian
(south Indian) population are affected by any of the three above mentioned obesity trends. The
GO and AO obesity is mostly prevalent among the ethnic population of India residing in
Chandigarh, Tamil Nadu, Jharkhand and Maharashtra. The prevalence of obesity is highlights
among the ethnic population residing in Chandigarh and the reason highlighted against this is,
Chandigarh is an urban city with high level of industrialization. This has promoted an increase in
the rate of obesity among the ethnic adults residing in Chandigarh. According to the National
Family Health Survey -3, the prevalence of obesity among the ethnic groups of women in India
is highest in Tamil Nadu followed by Maharashtra and Jharkhand. The group of the ethnic
population who suffer from the increased tendency of obesity mainly resides in the higher socio-

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economic groups. The Jaipur Heart Watch studies conducted a study which highlighted that the
occurrence of generalised and abdominal obesity is mostly high among the urban population in
comparison to the rural population. Asian Indians who are residing in northern part of India,
Delhi experiences a tendency of developing abdominal obesity which is defined as the
accumulation of the visceral fat in the abdominal area of the body and this tendency is termed as
Asian Indian phenotype. Chennai Urban Rural Epidemiology Study highlighted that in the city of
Chennai in Tamil Nadu, the generalized obesity is popular in comparison to the abdominal
obesity (38).
In the gender based differentiation of obesity, it was elucidated that ethnic Indian women
are more vulnerable in gaining weight in comparison to men. Women of all the age group
starting from 35 to 70 years are vulnerable in gaining weight. The higher prevalence of obesity
among the women in comparison to men is mainly popular among the three different Indian
states namely Tamil Nadu, Maharashtra and Jharkhand [38].
Dietary habits and obesity
Irrespective of the continental or reference of any country, it can be stated that obesity is
mainly influenced by the dietary habits and in India also one of the prime factors contributing
towards the increase the development of obesity among the ethnic population is dietary habits.
The cross-sectional study conducted by Agrawal et al. (2014) highlighted that the consumption
of the lacto-ovo vegetarian diet and lacto-vegetarian diet increases the tendency of developing
obesity as it increase the overall BMI index. Increase in the BMI index is associated with
increase in the prevalence of type 2 diabetes mellitus especially among the older adults between
the age group of 40 to 70 years and this in turn increases the tendency of gaining weight abruptly
[39]. In relation of obesity and diabetes, Kaveeshwar and Cornwall (2014) established a

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completely different view. Kaveeshwar and Cornwall (2014) highlighted that India has high rate
of occurrence of diabetes in comparison to the western countries. The trend indicates that
diabetes can occur at much lower body index or mass (BMI) among the Indians in comparison to
the Europeans. Thus it can be sated that Indian who are relatively lean and with lower BMI in
comparison to the Europeans are have equal risk of developing diabetes [41]. This development
of diabetes as a result of poor dietary habits further promotes the development of obesity among
the ethnic Indian population [41].
The study conducted by Aggarwal et al. (2014) highlighted that the majority of the obese
adults of ethnic Indian population are concentrated among the north-western fringe of India,
especially in Punjab. In Punjab, there is a trend in consumption of the non-vegetarian diet with
high content of butter. This unhealthy diet plan increases the obesity trend among the ethic group
in India [40]. Moreover, in India, especially in the ethnic groups residing in India, there is a trend
to replace snacks with meal and this extra consumption of food further promotes obesity. This
tendency is mostly popular among the ethnic groups residing in the urban regions of Delhi and
Punjab in comparison to the ethnic Indian population residing in the western fringe of India like
Gujarat, Maharashtra and Karnataka. Among the ethnic Indians there is a tendency in
consumption of high carbohydrate containing food along with fat rich food containing ghee or
butter leads to the formation of unsaturated fatty acid deposition in the adipose tissue which in
turn increases BMI leading to the development of obesity [42]. Moreover, ethnic Indians have a
tendency to consume foods which are rich in glucose content or sweet dishes. In Indian
especially among the ethnic population there are different festivals throughout the year like
Onam, Pongal and Hampi festival. In all these festivals preparation of sweet dishes are
mandatory like Palada Pradhnam, Semiya Payasam, Unni appam, Dry fruit kesari, Pazham proi.

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All these dishes are rich in glucose content as they contain high percentage of sugar and milk.
Consumption of these foods increases the overall calorific intake among the ethnic Indian groups
and thereby increase the trend of obesity along with the development of Diabetes. In north and
eastern part of Indian also the ethnic race is known for their numerous cultural festivals. These
cultural festivals are brimmed with sweet dishes and desserts like in case of Diwali and Holi
[43]. Consumption of sugar-sweetened beverages (SSBs) is a major determining factor behind
the increase trends of obesity and over-weight among the ethnic Indians. This trend is higher
among both the older adults and also among the younger adults as the food habits of both the age
group is influenced by their culture and thus increasing the trends in obesity. However, the adults
are more affected in comparison to the younger adults of adolescents because, older adults
between the age group of 40 to 70 years suffer from lack of adequate physical exercise and
increase in the level of stress along with other predisposition of lifestyle diseases like diabetes
and hypertension which make them more vulnerable in gaining weight [44].
Genetic factors and obesity
Kaveeshwar and Cornwall (2014) highlighted that the Indians are mainly generically
predispose in the development of the coronary heart disease due to high level of deposition of
low-density lipo-protein or bad cholesterol. This tendency of high cholesterol level among the
ethnic groups in Indian increases the tendency of gaining massive weight during the later part of
life in comparison to the Caucasians [41]. Moreover, the ethnic Indians like the Dravidians and
the Sikhs who are residing in the southern and in the eastern part of India have a genetic
predisposition of developing high blood pressure or hypertension. Blood pressure is a heritable
trait and is influence via several environmental stimuli and biological pathways. The main
environmental stimulus which increases the trend of developing high blood pressure includes

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high level of stress and unhealthy life style like high consumption of alcohol and smoking. The
biological factors which increase the development of high blood pressure include unhealthy diet
and increase in the tendency of cholesterol retention by the body. This increase in the tendency
of cardiovascular disease among the ethnic Indians are high due to prevalence of high blood
pressure of hypertension. Even a minute increase in the blood pressure is associated with high
risk of developing cardiovascular events. This increase in the level of cardiovascular disease
among the ethnic older adults of India increases the trend of developing obesity and fast weight
gain. The main gene which increases the pre-disposition of hypertension tension among the
Asians includes FURIN-FES, GOSR2, GUCY1A3 – GUCY1B2 and NPR3- C5orf23 [9]. The
genome-wide association study (GWAS) highlighted that the Indians especially the Sikhs
residing in the northern parts of India have genetic predisposition towards the development of
type 2 diabetes mellitus and this increase in the genetic tendency of sugar retention with the body
fluid increases the trend of developing obesity among the older adults in India [45].
Ethnicity and Obesity
Association between ethnicity and obesity has been documented in a number studies. For
example, high risk of obesity is mainly associated with the black women in comparison to
whites. It is due to this reasons that the ethnic groups in Indians like the Dravidians have higher
risk of developing obesity. Moreover, the people ethnic Indians like those who are residing in the
southern fringe of India have higher level of fat deposition per unit in comparison other
population group residing in India. The high rate of BMI increases the trend of developing
obesity since childhood among the ethnic Indians which in turn increases the risk of developing
obesity in the later stages of their life. India is multiethnic country this ethnic difference is
represented in the deposition of adipose tissue increasing the risk of obesity and cardio-vascular

24NARRATIVE REVIEW
disease among the ethnic Indians [47]. General fat deposition as assessed by BMI and fat
percentage within the body is found to be highest among the ethnic population of Delhi
especially among the females. However, fat deposition is found throughout the body in a uniform
rate within the ethnic population in Delhi. However, in the ethnic population of Manipur, the fat
deposition is mainly centralised. The centralised fat deposition among the ethnic groups of
Manipur is mainly facilitated by their type of physical activity and lifestyle. For example, people
residing in Manipur or in other hilly areas in India have better respiratory efficiency along with
an adaptive role of high physical activity in hilly terrains. This prevents the overall deposition of
fat within the body unlike those of the ethnic population residing in Delhi. More trunkal fat is
found to be directly related with the cardio-vascular disease prevalence among the ethnic groups
in India and thus acting as a direct indicator of the chances of developing cardiovascular disease
[48]. The ethnic differences in adipose tissue deposition mainly stem from environmental and
genetic sources and this further aggravated by the increase incidence of hypertension among the
ethnic Indian population. Kerala men have high diastolic blood pressure in comparison to the
other ethnic groups and their female counter part. This high tendency of diastolic pressure among
the Kerala increases their threats of developing hypercholesteromia and thereby leading to the
development of obesity. Though ethnic difference is seen among the South Indians, North
Indians and North East Indians, there average trend of high tendency of weight gain is high
among the people from the ethnic background in India [49].
Obesity is termed as ‘New World Syndrome’ as it is one of the primary non
communicable disease which affects a range of low socio-economic and developing countries.
Being the second most populated country in the world, India comprises in the 16% death of the
world population [50]. In a study conducted by the National Family Health Survey (NFHS), it

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was determined that most of the urban areas in the country has higher percentage of overweight
people than the rural areas where people with under nutrition were in higher percentage [51].
Further another study conducted to determine the health behaviors and associated problems in
young adults in India and it was found that there were several nutritional, mental illness, injuries,
and high risk sexual behavior [52].
Physical activity and obesity
The first research article included in the study mentions that increasing physical inactivity
and sedentary lifestyle is one of the leading cause of obesity in India and to provide proper data
regarding the same, they conducted a study across India as a part of the Indian Council of
Medical Research-India Diabetes (ICMR-INDIAB) study [53]. This study was conducted in two
phases, in phase 1, Tamil Nadu, Maharashtra, Jharkhand and Chandigarh was chosen to
represent the east, west, north and south portion of the country [54]. Further, to assess the
physical activity of the 213 million people around the region, a global physical activity
questionnaire was created so that data from such huge population can be collected and assessed
to present a feasible data [55]. After the study it was determined that from all those regions,
54.4% people were found inactive and leading a sedentary lifestyle whereas only 40% of the
people were found active [56]. Therefore, this study was able to provide data regarding the
inactivity level of people of India, which is one of the primary reason for prevailing obesity in
the country [57]. Researchers also mentioned that due to increased use of technologies in
occupational and home works, people have decreased their total metabolic energy depletion, day
by day activities and in this course the paper presented the trends of India from the year 200 to
2005 and determined that such sedentary lifestyle affected the people of India with higher risk of
cardiovascular diseases, weight gain and increased obesity [58].

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However, despite the increasing risk of obesity throughout the Indian population, the
rural population is less prone to such health complications that the urban population [59]. This
aspect of rural and urban food, diet and health related differences were presented in the research
where it was mentioned that increasing morbidity and mortality rates in urban India was due to
unhealthy dietary practices and increased physical inactivity due to increased proficiency of
technologies [60]. As the study did not had any evidence of the same, they conducted a WHO
questionnaire based study in the rural and urban regions of Punjab, a state of India and found that
15.1% of population of urban population were prone to obesity due to their inactive physical
level with compared to 9.2% of rural population [61]. Therefore, above studies indicated towards
the trend that decreased physical activity and increased sedentary life style which is a result of
extensive use of appliances and technologies that restrict people from performing minimal
physical activities could be one of the primary reasons for increased rate of obesity within Indian
population [62]. However, a critique to the above mentioned research articles was presented by
researchers in which the researchers mentioned that extensive physical activity does not make
people free from the risk of increased obesity [63]. The researchers provided a data that
mentioned that societies with high and low prevalence of obesity does not show any changes in
their energy consumption and energy depletion as well as the researchers also presented an
observational study which shows no association between energy expenditure and visible weight
change in the study [64]. Therefore, it could be stated with support of the research that Indian
population, where people are less associated with physical activities and are leading a sedentary
life, are more prone to obesity related conditions, however there are several researchers, who
provides a strong argument against the research findings and hence, indicated towards the need

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of future research in this domain of physical activity and its affect in increasing or decreasing the
prevalence of obesity [65].
Sugar intake and obesity
Food habit of India varies completely from the rest of the world as the diet mostly
comprised of sweet and sweet dishes [66]. In this case, it should be mentioned that in most of the
Indian religious and auspicious events, sweet is considered to be most sacred and appropriate
offerings to the God and to the entire society as it helps in spreading the joy and excitement to
the entire community [67]. Therefore, the population is more familiar to the taste of sweet than
any other food flavors and tastes. In a research conducted by researchers, it was mentioned that
Indian food habit, cultural preferences and social prevalence of a certain kind of food indicated
towards the fact that sugar intake is associated with higher risk of obesity [68]. The researchers
supported their fact from the data that India is the largest consumer of sugar in the world and also
the second largest producer in the world. It was also provided that as per the data collected from
NSSO, per capital consumption of jiggery in India in the year 2001 was approximately 9 kg per
annum [69]. Therefore, it indicated towards the fact that Indian food habit included sugar, curd,
ghee, honey, jaggery and other high carbohydrate products which are responsible for increasing
the risk of obesity [70]. Other than these, the Indian snacks, such as buttermilk, milkshakes,
sweetened drinks, cakes and biscuits are high in energy content and can increase the risk of
obesity among the population [71]. Therefore, it has been observed that populations, in which
such high sugar cuisines are consumed are more prone to obesity such as the Punjabi cuisine,
Rajasthan (Marwari) cuisine, Bengali cuisine, as these cuisines are rich in sugar and related food
products, making people consuming such foods prone to obesity compared to their regions [72].

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Socioeconomic status and obesity prevalence
Dravidians are one of the biggest ethnic groups in India and majority of them reside in
South India (73). A research study done in 2016 gave an insight into the prevalence of obesity in
people living in South India. The study aimed to evaluate the prevalence and associated factor of
obesity in people living in Theni district of Tamil Nadu. Cross-sectional institutional based study
was done to identify the factors contributing to obesity in ethnics Indians. The collection of data
from government hospitals and primary health care centers in Tamil Nadu revealed prevalence
rate of 52.4% in adults and higher rate in females compared to males. In addition, the statistical
analysis also revealed high rate of obesity prevalence in people between 18-34 years compared to
people above 50 years. The likelihood of obesity was high in married partners. The strength of
the study is the use of statistical method to interpret wide range of data related to obesity
prevalence. The study revealed gender, diet, physical activity, socioeconomic status and
educational factors are associated with increase in obesity prevalence (74). This is supported by a
research evidence which states that understanding of socioeconomic patterns of obesity across
lifetime is essential as social class significantly affects health and predicts the risk of obesity
(75).
Another research also found evidence for prevalence of obesity in rural regions of
Southern India. In response to the double burden of over-nutrition and under-nutrition, the
authors collected a random sample of adults between 20-80 years of age and information were
collected from participants related to diet, physical activity, rurality, socioeconomic positions
and BMI. The prevalence of obesity was found to be 16.1% for class I obesity and 3.3% for class
II obesity. High risk of obesity was found due to low physical activity, high wealth index, no
livestock, television ownership, high caste and low rurality index (77). The strength of the

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evidence is that major variables were measured using validated tools which minimize the
possibility of increase in biases because of self-reporting measures of research findings. The
research justified the cause behind the impact of different factors on obesity prevalence. For
example, physical activity was linked to obesity because of the effect of modernization in
contributing to physical inactivity (78). Farming process has become less strenuous and influx of
vehicle has reduced need for active transportation. In the context of rurality index, it has been
found that greater rurality is associated with lower BMI and decreased odds of obesity and
underweight (78).
Television ownership and TV time:
As the television ownership has increased in India, the number of people with high BMI
and increased odds of obesity has increased (76). Although the link between obesity and
ownership of household device has not been explored only for India, however the same has been
done for high, middle and low income countries. In case of low middle countries, India was
taken as one of the countries. The selection of middle and upper income countries also reflects
the approach to interpret economic heterogeneity in social environment and understand its long-
term impact on health. Increased household device ownership was significantly regarded as a
factor contributing to risk of obesity. Three household devices were common among participants.
Television was the device with the largest ownership followed by car and a computer. High
income countries were found to have all the 3 devices whereas low income countries only had
lower number of devices. Device ownership is found to increase rate of obesity as it increases
sitting time, waist circumference, BMI and decrease physical activity. The trend was found to be
high in low income countries like India (79). However, one limitation of the study was that it
could not interpret causal association behind device ownership and obesity. It gives the

30NARRATIVE REVIEW
implication to reduce sitting time and sedentary behaviour to prevent obesity in target
population. Environmental cues that contribute to sedentary lifestyle and unhealthy behavior
should be identified particularly for children. This will help to reduce access to unhealthy
behaviours and encourage participation in activities that establish new and healthier daily
routines (80).
Strategies to prevent obesity in ethnic Indian population
The review of factors contributing to obesity in ethnic Indians suggests that sociocultural
factors play a dominant role in the prevalence of obesity. Race and ethnicity characterize
populations into different groups. Although obesity prevalence is high in Delhi, Kerala and
Punjab, however the trend towards increase in weight is also increasing in South India. As ethnic
groups also reside in Tamil Nadu state, an observational study was done to collect data related to
obesity prevalence in the people living in Villupuram district of Tamil Nadu State in India.
Overweight was found to be common among females compared to males and obesity was highest
in male compared to females. The data suggest an increase in prevalence of obesity in rural areas
(81). There is a need for strategies that is implemented in rural setting to control the factors that
contribute to obesity in certain population group in India. Review of interventions on best
strategies to prevent obesity in rural areas suggests intervention program targeting parents as
important to reduce the risk of obesity in rural setting. A study revealed that health educational
program providing education to parents can encourage people to choose the right food, include
large number of fruits and vegetables in diet. Such programs also have the potential to create
accessible physical environment to promote physical activity and reduce sedentary time in
individuals (82). Hence, it can be said that parents are at unique position to promote behavioural

31NARRATIVE REVIEW
change in children and families and reduce the epidemic of obesity in certain sections of the
Indian population.
Preventing obesity:
Due to the effect of media and advertising and the increase in television viewership, there
is a need to target mass media as a tool to influence attitude of ethnic Indians towards unhealthy
food and improve their dietary habits (83). Mass media can play an effective role in preventing
obesity as this has been proved by a research which used mass media to raise awareness about
sugar in beverages. The campaign was implemented through web, television and transit and a
telephone based survey method was used to measure attitude towards obesity, knowledge related
to excessive sugar and behavioural intentions related to sugary drink consumption. Positive
effect of the mass media was found as the results revealed that 80% of people intended to reduce
consumption of soda and sugary drinks after being aware of the media campaign (84). Hence, it
shows that media campaign can be used to address obesity in other social context too. However,
the content of the program needs to be changes as per the language and preference of the target
population group. Longer follow up of such program is also needed so that constant
improvement in overweight and obesity related statistics are achieved.
In response to the issue of low physical activity seen in ethnic Indians, there is also a
need to implement actions that change attitude of ethnic Indians towards physical activity and
increase their knowledge regarding harmful consequences of obesity. Urbanization is one factor
that has lead to massive change in lifestyle and diet preference of people. In case of research
done for ethnic people living in districts of South India, it has been found that effect of
urbanization has contributed to improvement in rural areas. For example, transport facilities,
medical care, education and family income has improved. All these changes have cumulatively

32NARRATIVE REVIEW
led to increase in body mass index and changes in lifestyle of rural and ethnic dwellers (85).
Hence, as changing lifestyle has been identified as one of the contributing factor for rise in
diabetes and chronic disease like diabetes in Indians, there is a need to identify innovative
strategies that can help the target group to lead a physically active lifestyle.
Traditional approach can be adopted to control obesity epidemic. For example, a study
suggested innovative option of using traditional dance styles and yoga as an approach to prevent
obesity. Yoga is the most secular and cost-effective method that can be adopted by many people.
It can encourage young generations to remain healthy and poised. Yoga has gained acceptance
globally too and it has the chance to be adopted by large number of people in India. It has the
potential to be accepted too. Recent research evidence suggests that yoga has the potential to
reduce stress level and improve eating habits. It can reduce stress level and reduce weight too. A
randomized controlled trial done with people decided into (86)

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Discussion:
Introduction
Obesity is an important health risk which requires no introduction in the present day
scenario. What is crucial is the requirement of the proper elucidation of the environmental
factors along with the proper prevention strategy. In India, the prevalence of obesity is mainly
high among the ethnic population. Ethnicity is a complex construct of biology but also religion,
culture and language for the epidemiologist. Ethnic groups have different health beliefs and
health behaviours. The study of the ethnic groups is of prime importance in determining disease
trends, disease risk and the disease prevalence. However, the study of single ethnic group is not
comprehensive in determining any particular health-trend. In order to study the trends in obesity
among the ethnic groups of India, three main ethnic populations residing in India has been
selected [87]. The three main ethnic Indian population residing in India include Indo-Aryan
(North-Indian), Mongoloid (North East Indian) and Dravidian (South Indian). These ethnic
groups are further sub-divided into numerous other sub-groups, tribes and cast in India. The main
risk factors which are found underlying the disease development include socio-economic status,
dietary habits, lack of physical activity, and influence of television advertisements, sedentary life
style and other genetic and ethnic pre-disposition [51].
The main reasons behind the increased prevalence of obesity among the ethnic Indians
The main reasons behind the increase in obesity among the ethnic Indians include
consumption of high sugar diet or high calorie food mainly during the festive seasons throughout
the year. Apart from the high-calorie food intake, other factors which promote the disease

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development include unhealthy diet among the ethnic Indians. The ethnic Indians have a
tendency to follow diet a plan which is rich in ghee and butter along with extended snacks and
late night dinner [52]. This diet with high content of fat and irregular interval of food intake,
increases the tendency of developing high level of blood cholesterol which in turn increases the
trend of developing obesity [89]. This trend in obesity is higher among the North Indians
especially people who are residing in Delhi. The ethnic groups of North India are mainly the
victims of abdominal obesity due to increase in consumption of ghee butter and other sweet
dishes [52]. In the southern part of India, or among the Dravidians there is an increase in the
trend of generalised obesity. This increase in the trends of generalised obesity is due to the high
consumption of carbohydrates among the South Indian population [89]. Moreover, the ethnic
groups of Indian have a tendency of consuming aerated soft drinks which again increases their
risk of gaining massive weight [54]. In India especially the ethnic groups are indulged in
different cultural activities which increases the rate of consumption of deserts or sweet dishes
which again increases the risk of gaining weight [56].
The factors underlying the trends in obesity among the ethnic Indians
The analysis of the research articles highlighted that in India the prevalence of obesity is
mainly high among the all the ethnic groups who are residing in Chandigarh, Tamil Nadu,
Jharkhand, Punjab, Maharashtra, Kerala and Punjab. The prevalence of obesity is mainly high
among the females in comparison to males. Three different types of obesity popular among
ethnic Indians include abdominal obesity, combined obesity and generalised obesity. The main
socio-economic factors which are guided behind the disease development include rapid
urbanization and industrialization [51]. The advent of the 20th century in Indian subcontinent is
highlighted by increase in the trend of industrialization and urbanization in the majority of the

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sates in India. The increase in the industrialization lead to an increase in the flow of cash and
employment options along with an increase in the trend of unhealthy life-style which lead to an
increase in the development of obesity among the Indian population especially among the ethnic
Indians [88]. Genetic factors also increase the trend of developing obesity among the ethnic
Indian population [54]. Increase in the genetic pre-disposition increases the risk of developing
cardiovascular diseases and diabetes mellitus among the ethnic Indians [59]. The development of
cardiovascular disease and type 2 diabetes increases the risk of developing obesity among the
ethnic Indians [90]. Furthermore, increase in the ethic Asian have genetic predisposition of
developing of hypertension which increase the risk of developing obesity further. The ethnicity
also increases the overall risk of developing obesity. The ethnic Indians have high BMI along
with general fat deposition throughout the body. Increase in the fat deposition throughput the
body leads to increase in the body mass and overall-body weight. This cumulates into obesity
[60]. In general among the ethnic groups with black skin colour have higher tendency of again
weight in comparison to white skin individuals. It might be due to low BMR (basal metabolic
rate). Low BMR decreases the overall absorption and utilization of the calorie within the body
and thereby leading to the gain in weight. This tendency of poor BMR causes high rate of trunkal
fat along with high belly fat [62]. Obesity with high belly and trunkal fat increases the
cardiovascular risk.
While discussing the obesity patter in India and its relation to decreased physical activity,
the research article by [53] should be mentioned as it was one of the largest study that included
the physical activity related pattern in India. This study concluded that nearly half of the
population in the four regions of India taken under assessment are physically inactive and this
inactivity was present in rural areas more than that of the urban areas [55]. Further the data

36NARRATIVE REVIEW
collected from the study also revealed that females were more inactive than male counterparts
and within these most of the people blamed their moderate to low active work culture or
professional life for their decreased inactivity [58]. The primary finding of the study was
increasing physical activity in females than men and prevalence of higher inactivity in urban
areas [59]. It was also found from the survey conducted in the state of Tamilnadu that
determined that such inactivity starts from major cities which eventually decreases through
smaller cities, towns and then level of activity increases in the rural area. researchers also
mentions that the primary reason behind this is the availability of resources that restricts or limits
the scope of physical activity for people living in bigger cities or town, on contrary rural areas
are deprived of such technologies that forces them to perform those tasks manually, hence, he
shift of obesity is observed from urban to rural areas [54]. Further another research indicated that
les physical work related occupation, higher level of income and other factors led the individuals
living in urban India develop obesity compared to the population in rural India [60]. Therefore,
from these studies under the theme of physical activity mentioned that more than 30% of the
population in India are under the risk of development of obesity and for this, manmade
technologies and appliances are responsible [59].
Dietary and nutritional habits are another reason for increasing obesity in India. Research
provides a detailed analysis of the cuisine and diet related preferences of people in India and
mentioned that the food and dietary habits includes sweets and sugar related products in large
amount as in every ethnic, auspicious or traditional occasions, Indian population prefer sweets or
sugar related products for offerings to the guests, society and to the God [66]. Therefore, their
diet and cuisine related impact are witnessed in their obesity pattern [69]. Further, findings from
the research it was determined that as sugar or carbohydrate is the primary source of energy in

37NARRATIVE REVIEW
Indian cuisine and the level of physical activity is continuously decreasing, the level of obesity
increasing in the Indian population [71]. further it also mentioned that such rate and increase is
visible in portions of the country where such sugar rich cuisine are used for daily food habits and
consumption, such as Punjab region, Bengal region, Rajasthan region and so on [70]. Therefore
these populations are much more probe to obesity than the south Indian community of India. In
such situation, the researchers aimed to understand other factors such as the socio-economic
factors, influence of advertisements and others on the increasing obesity of Indian population
especially children across the country (67). Socio-economic conditions and availability of
education are few of the important factors which affects the physiological condition of individual
and make them prone to obesity. In Indian society, education is one of the important factors as
most of the population are not being able to reach to the educational level required to lead a
healthy and balanced life [29]. Therefore, they are much more prone to dietary and nutritional
imbalance and hence are much more prone to obesity than the community who are aware of the
dietary and nutritional preferences which can prevent weight increase and obesity [30]. Further
sound socio-economic status helps individual to reach to quality healthcare, social stability
helathcare means using which obesity could be prevented. Hence, it should be mentioned that
educational availability, sound socio-economic status are important factors to determine the
obesity condition and its prevalence in a society [90].
For this purpose, research was conducted in the south Indian community and in the state
of Tamil Nadu and this study done in 2016 revealed that there is a range of factors that
contributes in the obese condition of common Indians [75]. The rate of obesity was higher in
married couples, females compared to men and was likely to affect people between the ages of
18 to 34 [73]. While discussing these, the researchers identified that socio-economic factors,

38NARRATIVE REVIEW
mental and psychological conditions are few of the aspects that influences people and their
obesity condition [78]. Further, gender, diet, nutritional factors, genetic, educational level and
physical activity levels also contributed in the enhancement of the obesity related condition in
population of India [76]. Further, while discussing the aspect of obesity in urban India, the effect
of television and different food product advertisements should also be mentioned. Researchers in
their research article mentioned that television or ownership to such devices has been seen to
affect the physical activity related condition in low, medium and high income countries and
hence, the effect of the same ion Indian population cannot be denied [77]. Not just television, but
also ownership of a range of electronic devices has completely restricted the physical activity
related scopes of Indian population, Further, there are certain food products which are being
advertised around the society, consumption of which is responsible for such increase in the
weight and enhancing obesity condition [78]. Hence, this research article also indicated towards
the fact that sedentary lifestyle, deformed food habit and decreased physical activity is affecting
the health wellbeing of a large section of population in India Therefore, such obesity related
conditions require specific interventions and health care management so that such condition can
be controlled [75].

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Conclusion:
On a concluding note, obesity can be defined as the condition that has become one4 of
the greatest public health priorities all across the globe. Along with that, it is very important to
acknowledge while discussing the impact of obesity as a nation-wide health issue or adversity,
that obesity is the gateway for far more complicated and complex co-morbidities affecting the
lifestyle and life expectancy of the target population. On a more elaborative note, obesity is
intricately linked with various different comorbid disorders such as cardiac complications, renal
disorders, diabetes and many other related co-morbidities with the lack of adequate interventions
being provided. Hence, undoubtedly, obesity is a preventable health issue which requires vigilant
preventative monitoring and lifestyle modifications to control, although the lack of proper
education, health literacy and infrastructure are considerable restrictive factors complicating
better management of rising obesity statistics. The developing nations are far more affected by
the obesity statistics than the developed nations, and the most notable contributing factors to the
disparity of the incidence and prevalence is the lack of literacy or knowledge, lack of health
promotional infrastructure, and lack of national obesity prevention campaigning to address the
alarmingly rising rates of obesity.

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This narrative review has been successful in exploring the extrinsic and intrinsic factors
that are contributing to the obesity trends in India. The review has been successful in extracting
the data that indicates that the most of the obesity incidence rate is more in the Chandigarh,
Maharashtra and Tamil Nadu and the lack of education and literacy regarding obesity, its impact
and how to prevent is the most important factors that are facilitating the high risk of obesity.
Along with that, the review also identified the fact that gender based differentiation in the obesity
statistics is also more prominent in the ethnic Indian women especially in Tamil Nadu.
Maharashtra and Jharkhand especially for the lack of knowledge and reduced living conditions.
Along with the dietary habits and knowledge level, genetic predisposition has also been reported
to be considerable contributing factors contributing to obesity in the Indian population. Indian
ethnic populations are genetically predisposed to coronary heart diseases due to the extreme level
of low-density lipo-protein or bad cholesterol, which has contributed to massive weight gain
bouts as well.
However, the narrative review also has identified the attitude of the Indian population
towards physical activity as one of the most important contributing factors giving rise to obesity.
The articles reviews indicated that the Indian populations are far more accustomed with
sedentary lifestyle and coupled with the lack of any knowledge or understanding of the
detrimental impacts of sedentary lifestyle, the risk of obesity is higher among these populations.
Furthermore, the lack of any inclination towards a regular physical activity regimen has been
discovered to be extremely less in the Indians, especially in the Ethnic Indian populations (5). On
a more elaborative note, almost 50% of the Indian population has no better understanding of the
need of maintaining a daily exercise regimen and how it helps in preventing these avoidable non-
communicable diseases such as obesity. Hence, the tendency towards maintaining a more

41NARRATIVE REVIEW
sedentary lifestyle devoid of a mildly rigorous and regular exercise regimen has facilitated the
risk of obesity among the Indian population as well. Lastly, the level of sugar intake also is
identified in the review as the most important factor among the Indian demographics leading to
the high rate of obesity and related co-morbidities. Sweets are an integral part of Indian cultures
and along with that having sweets are essential for various auspicious events as per Indian
culture as well. Furthermore, for many conventional cultural groups, sweets are a part of every
meal and then most of the Indian families religiously abide by these cultural norms for
generations which has led to the population having very high sugar intake ratio further
heightening the chances of acquiring note just obesity, but diseases such as diabetes as well.
Hence, it is clear that the lack of literacy and knowledge to improve dietary habits and engaging
in physical activity are the most important contributors to the rising obesity in India, and these
factors are variable determinants that can be modified with adequate efforts being taken both
nationally and locally (4). On recommendation, taking the aid of digital and social media to
spread awareness regarding the obesity and how to effectively manage it can help the population
undertake lifestyle modifications. Along with that, health promotional campaigns and screening
for different population setting can also help in enhancing the knowledge of the target population
and improve their dietary and lifestyle habits.

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55NARRATIVE REVIEW
1. Search summary
Database used Search terms used Number of hits obtained
Medline obesity and ethnic Indians 75
Medline Obesity prevalence and ethnic
Indians
56
Medline Cause of obesity in India 110
CINAHL Obesity prevalence in India 45
CINAHL Cause AND prevalence of
obesity OR obese individual in
India
36
2. Screening process:

56NARRATIVE REVIEW
Records identified through
database searching
(n = 157)
Additional records identified
through other sources
(n = 15 )
Records after duplicates removed
(n =60 )
Records screened
(n =127 )
Records excluded
(n = 55 )
Full-text articles assessed for
eligibility
(n = 72 )
Studies included in
qualitative synthesis
(n = 23 )
Full-text articles
excluded, with
reasons
(n = 49 )
3. Summary table for studies used in the narrative review

57NARRATIVE REVIEW
Author Aim Theme Outcome
Pradeepa R, Anjana
RM, Joshi SR, Bhansali
A, Deepa M, Joshi PP,
Dhandania VK, Madhu
SV, Rao PV, Geetha L,
Subashini R
The study aimed
determining the
prevalence of
generalized, abdominal
and combined obesity in
urban and rural India.
Prevalence and cause of
obesity in India
Female gender,
hypertension, diabetes,
higher socio-economic
status, physical
inactivity and urban
residence are associated
with obesity in India
Agrawal S, Millett CJ,
Dhillon PK,
Subramanian SV,
Ebrahim S.
To investigate the
prevalence of obesity
and diabetes among
adult men and women in
India consuming
different types of
vegetarian diets
compared with those
consuming non-
vegetarian diets.
Causes of obesity Lacto-, lacto-ovo and
semi-vegetarian diets
were associated with a
lower likelihood of
diabetes.
Ranjani H, Pradeepa R,
Mehreen TS, Anjana
RM, Anand K, Garg R,
Mohan V
Discussion on factors
predicting obesity in
India
Prevalence of obesity Details on Asian Indian
context provided

58NARRATIVE REVIEW
Kaveeshwar SA,
Cornwall J
Report on etiology of
diabetes
Prevalence and cause Multicenter outcome
provided
Singh, M. and
Kirchengast, S., 2011.
To determine the
prevalence of obesity
and overweight
among Indian women
living in Punjab, India
and in Vienna,
Austria. A
Prevalence and cuase Relation between diet
and weight status found.
Vivek M. To evaluate norh Indian
festivals aand their
impact on health
Causes Festivals increase
consumption of energy
rich food
Hu FB Review on decreasing
SSB consumption will
reduce the prevalence
of obesity and its
related diseases
Prevention Positiev outcome found
Saxena, R., Saleheen,
D., Been, L.F.,
Garavito, M.L., Braun,
T., Bjonnes, A., Young,
R., Ho, W.K., Rasheed,
A., Frossard, P. and
Sim, X., 2013.
Genome-wide
association study done
Causes Genetic association
found
Ehret GB, Munroe PB, Report on pathways Cause Insights into genetics

59NARRATIVE REVIEW
Rice KM, Bochud M,
Johnson AD, Chasman
DI, Smith AV, Tobin
MD, Verwoert GC,
Hwang SJ, Pihur V
influencing blood
pressure
and causal pathway
Mungreiphy NK, Dhall
M, Tyagi R, Saluja K,
Kumar A, Tungdim
MG, Sinha R, Rongmei
KS, Tandon K,
Bhardwaj S, Kapoor
AK.
To study the relation
between obesity and
ethnicity
Causes People coming from
ethnic group has marked
differences in obesity
and body weigh
statistics
Tillin T, Hughes AD,
Godsland IF, Whincup
P, Forouhi NG, Welsh
P, Sattar N, McKeigue
PM, Chaturvedi N.
Extent of obesity in
Asian Indians in UK
Causes Truncal obesity is
highest in Indian Asians
Marzuillo P, del Giudice
EM, Santoro N.
Role of ethnicity and
geneticity
Causes Role of ethnicity in
diseases
Anjana RM To assess physical
activity patterns
across India
Causes Large percentage of
Indians are inactive
Ng SW, Popkin BM. Details related to
sedentary activities
globally
Cause Results related to
physical inactivity
related

60NARRATIVE REVIEW
Tripathy JP, Thakur JS,
Jeet G, Chawla S, Jain
S, Prasad R.
To assess urban rural
difference in dietary
habits in India
Causes Poor dietary
practices and
physical inactivity
seems to fuel the
non-communicable
disease epidemic in
India.
Misra A, et al. Diet and physical
activity assessment for
Asian Indians
Causes Asian Indians are
more sedentary than
white Caucasians
Luke A, Cooper RS. Risk factor of obesity Prevention Public health message
Rajalaksmi Murugan
and Maria Therese
Prevalence of obesity in
Tamil Nadu
Cause Effect of modernisation
and lack of strenuous
activity on weight seen
Little Prevalence of obesity in
rural regions of
Southern India.
Causes High risk of obesity was
found due to low
physical activity, high
wealth index, no
livestock, television
ownership, high caste
and low rurality index
Lear SA link between obesity
and ownership of
Causes In case of India,
Television was the

61NARRATIVE REVIEW
household device
explored in low and
middle income countries
device with the largest
ownership followed by
car and a computer
Chauhan RC, Obesity in South
Indians
Cause High rate of obesity in
males.
Boles M, Adams A,
Gredler A, Manhas S.
Effect of mass media in
preventing obesity
Causes Mass media can address
obesity
Misra A. Ethnic criteria for
preventing obesity in
Asian Indians
Causes Ethnic specific criteria
for body mass index
defines